LCD/NCD Portal

L29252 PARAVERTEBRAL FACET JOINT BLOCKS

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

Medicare will consider facet joint blocks to be reasonable and necessary:

• For chronic pain (persistent pain for THREE (3) MONTHS or greater) suspected to originate from the facet joint.

• To document/confirm suspicions of posterior element biomechanical pain of the spine.

• Hallmarks of posterior element biomechanical pain are noted as:

o The pain does not have a strong radicular component.

And

o There is no associated neurological deficit.

And

o The pain is aggravated by hyperextension, rotation or lateral bending of the spine, depending on the orientation of the facet joint at that level.

 

Anatomical region:

• Facet joint is noted at a specific level, by the vertebrae that form it: (note levels of treatment)

 

o C-spine levels. (C4-5 etc.).

o T spine…levels.

o L-spine levels. (L2-3).

 

• It is further noted that there are two (2) facet joints at each level,

o Left.

o Right.

• Cervical/thoracic (64490, 64491, 64492). (Left and Right).

• Lumbar/sacral (64493, 64494, 64495). (Left and Right).

 

Coverage will be extended for only ONE type of procedure during one day/session of treatment UNLESS the patient has recently discontinued anticoagulant therapy for the purpose of interventional pain management.

• Paravertebral blocks, facet joint injections, and medial branch blocks per “Current Procedural Terminology (CPT) “were performed utilizing direct visualization with fluoroscopy and documented.

• Services will be considered medically reasonable and necessary only if performed by appropriately trained providers.

• A qualified physician for this service/procedure is defined as follows:

o Physician is properly enrolled in Medicare.

And

o Training and expertise must have been acquired within the framework of an accredited residency.

Or

o Fellowship program in the applicable specialty/subspecialty in the United States.

Or

o Must reflect equivalent education, training, and expertise endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States.

 

 

Limitations:

• An epidural block or sympathetic block would be provided to a patient on the SAME DAY as facet joint injections.

• MULTIPLE BLOCKS given on same day that could lead to improper or lack of diagnosis.

• Blocks performed WITHOUT the use of fluoroscopy are considered not medically necessary.

o (Per “CPT” Imaging guidance (fluoroscopy CT) and any injection of contrast are inclusive components of 64490-64495.)

• Services NOT performed by appropriately trained providers.

 

 

CPT/HCPCS Codes

 

64490 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL

64491 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

64492 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

64493 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL

64494 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

64495 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

(Per “CPT” Imaging guidance (fluoroscopy CT) and any injection of contrast are inclusive components of 64490-64495.)

 

 

ICD-9 Codes that Support Medical Necessity

 

719.48 PAIN IN JOINT INVOLVING OTHER SPECIFIED SITES

721.0 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY

721.2 THORACIC SPONDYLOSIS WITHOUT MYELOPATHY

721.3 LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY

721.41 SPONDYLOSIS WITH MYELOPATHY THORACIC REGION

721.42 SPONDYLOSIS WITH MYELOPATHY LUMBAR REGION

722.81 POSTLAMINECTOMY SYNDROME OF CERVICAL REGION

722.82 POSTLAMINECTOMY SYNDROME OF THORACIC REGION

722.83 POSTLAMINECTOMY SYNDROME OF LUMBAR REGION

723.1 CERVICALGIA

724.1 PAIN IN THORACIC SPINE

724.2 LUMBAGO

724.8 OTHER SYMPTOMS REFERABLE TO BACK

V58.61* LONG-TERM (CURRENT) USE OF ANTICOAGULANTS

* Use only as a supplemental code in addition to primary diagnosis, when anticoagulant therapy has been discontinued to facilitate therapeutic injections for pain management.

 

 

General Information

• Assessment of the outcome of this procedure depends on the patient’s responses, therefore documentation should include:

o Whether the block was a

 Diagnostic injection.

Or

 Therapeutic injection.

o Pre-operative evaluation of patient.

o Postoperative evaluation of patient.

o Patient education.

o Subjective responses from the patient regarding pain:

 Facet pain provocative maneuvers documented by:

• Pre-operative measurement.

And

• Post-operative measurement.

And

o Objective responses from the patient regarding pain, including:

 Facet pain provocative maneuvers documented by:

• Pre-operative measurement.

And

• Post-operative measurement.

• (According to ASIPP guidelines, a positive response to the paravertebral facet joint block is noted when a greater than 50% RELIEF of pain is obtained.)

• Placement of the needle at the facet joint MUST be performed under the fluoroscopic guidance to ensure safety and accuracy of the injection procedure,

And

• This MUST be documented in the patient’s medical record.

Utilization Guidelines

Diagnostic Phase

• Procedures performed during the diagnostic phase should be limited to THREE (3) LEVELS (whether unilateral or bilateral) for each anatomical region as defined in this LCD on any given date of service.

• A diagnostic block can be repeated ONCE, at any given level, AT LEAST ONE WEEK (preferably 2 weeks) after the first block.

• If repeated, strong consideration should be given to utilizing administration of an anesthetic of different duration of action.

o (This helps confirm the validity of the diagnostic facet block, and may reduce the incidence of false positive responses due to placebo effect).

• Once a structure is proven to be negative as a pain generator, NO repeat interventions should be directed at that structure unless there is a NEW clinical presentation with symptoms, signs, and diagnostic studies of known reliability and validity that implicate the structure.

Therapeutic Phase

• It is NOT expected that a patient would undergo a therapeutic block at more than THREE (3) LEVELS (UNILATERAL OR BILATERAL) per anatomic region on any given date of service.

• It is not expected that patients would undergo repeat treatment at same anatomic region at less than 90-DAY INTERVALS.

• It is also NOT expected that all patients will present with pain in both anatomical regions (cervicothoracic and lumbosacral), therefore the routine performance of facet joint/medial branch block (both diagnostic and therapeutic) to both regions may prompt a pre-payment review.

o Routinely exceeding the above parameters, by utilizing the procedure codes on the same beneficiary in unusual patterns may result in pre-payment review.

• Other interventional pain management procedures done on the SAME DAY as paravertebral facet joint blocks should be rare.

• In certain circumstances a patient may present with both facet and sacroiliac problems.

o In this case, it is appropriate to perform both facet injections and SI injection at the same session assuming that:

 These are therapeutic injections.

And

 Prior diagnostic injections (blocks) have demonstrated that both structures contribute to pain generation.

o The medical record must clearly support both procedures.

o Medicare recognizes that this is NOT common and will monitor the frequency with which these codes are combined.

o Multiple procedure modifiers will apply to intraarticular sacroiliac injection.

Treatment Logic:

• A paravertebral facet joint represents the articulation of the posterior elements of one vertebra with its neighboring vertebrae.

• Facet joint block is one of the methods used to document/confirm suspicions of posterior element biomechanical pain of the spine.

• During a paravertebral facet joint block procedure, a needle is placed in the facet joint or along the medial branches that innervate the joints under fluoroscopic guidance and a local anesthetic and/or steroid is injected.

• After the injection(s) have been performed, the patient is asked to indulge in the activities that usually aggravate his/her pain and to record his/her impressions of the effect of the procedure.

• Temporary or prolonged abolition of the pain suggests that the facet joints are the source of the symptoms and appropriate treatment may be prescribed in the future.

• Some patients will have long lasting relief with local anesthetic and steroid, others will require a denervation procedure for more permanent relief.

• Before proceeding to a denervation treatment the patient should experience at least a 50% reduction in symptoms for the duration of the local anesthetic effect.

• Diagnostic or therapeutic injections/nerve blocks may be required for the management of chronic pain.

• It may take multiple nerve blocks targeting different anatomic structures to establish the etiology of the chronic pain in a given patient.

• It is standard medical practice to use the modality most likely to establish the diagnosis or treat the presumptive diagnosis.

• If the first set of procedures fails to produce the desired effect or to rule out the diagnosis, the provider should then proceed to the next logical test or treatment indicated.

 

 

Sources of Information and Basis for Decision:

 

Boswell, M.V., Trescot, A. M., & et al. (2007). Interventional Guidelines: Evidence based practice guidelines in the management of chronic spinal pain. Pain Physician (10) 7-1111.

 

FCSO L29252 Paravertebral Facet Joint Blocks. rev 10/4/2011, database at www.cms.gov/medicare-coverage-database/

 

Manchikanti, L., Singh, V., Kloth, D., Slipman, C.W., Jasper, J., Trescot, A.M., Varley, K.G., Alturi, S.L., Giron, C., Curran, M.J., Rivera, J., Baha, A.G., Bakhit, C.E., and Reuter, M.W. (2001). Interventional techniques in the management of chronic pain. Pain Physician (1) 24-98.

 

Manchikanti, L., Singh, V. (2002). Review of chronic low back pain of facet joint origin. Pain Physician. 5(1) 83-101.

 

Manchikanti, L., (2004). Principles of documentation, billing, coding and practice management for the interventional pain professional. American Society of Interventional Pain Physicians and Anesthesiology. Retrieved form the Internet on April 25, 2007 via ASIPP.org

 

Miller, R.D. (2005). Nerve blocks in Miller: Miller’s Anesthesia, 6th ed. Philadelphia: Churchill Livingstone.

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

 

CMS LCD PARAVERTEBRAL FACET JOINT BLOCKS